How to Prepare for the Changes Affecting
Medicaid & the Uninsured
Stephanie Altman, Programs & Policy Director
Health & Disability Advocates
Cathy A Peterson, President, Peterson Healthcare Consulting
Peterson Healthcare Consulting
Overview of Health & Disability Advocates
• Lawyers, social workers and policy analysts on
staff
• Client Representation (SSI, SSDI, Medicaid,
Medicare)
• Medical Legal Collaborations include Cook
County Hospital
• Training and Technical Assistance to
Community Based Providers
• Policy/Advocacy (Medicaid, Health Care
Reform, Veterans, Military Families, Special
Education)
Peterson Healthcare Consulting
Overview of Peterson Healthcare Consulting
• Vast experience helping providers with:
• Strategic planning,
planning
• Business development,
• Managed care, and
• Revenue cycle
• Cathy has extensive Medicaid knowledge ranging
from being part a team that created the Family
Health Network to assisting FQHCs to enhance
their Medicaid strategy to a revenue cycle
turnaround for a 200 + MD practice whose
Medicaid mix is over 40%.
Peterson Healthcare Consulting
Learning Objectives
1 About the major upcoming changes
1.
in Illinois
g
2. The timeline for these changes
3. How the changes will affect
Hospitals and Physician Groups
4. Key Actions Providers should take to
retain the patients and maximize
income
Peterson Healthcare Consulting
Major changes based on 3 new laws
1. Affordable Care Act - Signed into law on March 23 2010
on March 23, 2010
2. Illinois Medicaid reform (Public Act
096 1501) – Signed in January 2011
096-1501)
3. More Illinois Medicaid reform (Public
A t 097-0689)
Act
097 0689) - passed in May 2012
Will first discuss the State reform as that
will affect providers sooner than the
Federal law. We will start with #2 above.
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Illinois Medicaid Reform signed in 2011
Five Major Changes:
1. Caps All Kids at 300% FPL for new enrollees after
7/1/2011 (grandfathers
(
df th
in
i currentt All Kids
Kid enrollees
ll
over
300% FPL until 7/1/2012.) - 4,000 children will no longer
be eligible for coverage.
2. Imposes new verification of residency, a potential eligibility
barrier, for Medicaid.
3 Moratorium on Medicaid eligibility expansions until 2013
3.
(extended now to 2015.)
4. Phasing out the practice of allowing unpaid bills from one
year to be paid in the next fiscal year
year.
5. Requires that 50% of Medicaid clients be enrolled in care
coordination programs by January 1, 2015.
Peterson Healthcare Consulting
Illinois Medicaid Reform signed in 2011
50% of Medicaid clients be enrolled in care
coordination programs by January 1
1, 2015
2015.
Care coordination will be provided to most Medicaid
clients byy “managed
g care entities,”
, ag
general term that
will include:
1. Coordinated Care Entities (CCEs),
2. Managed Care Community Networks (MCCNs) and
3. Managed Care Organizations (MCOs).
Peterson Healthcare Consulting
Illinois Medicaid Reform signed in 2011
• 2.7 million adults and children are currently
enrolled
ll d iin M
Medicaid
di id and
d All Kid
Kids iin Illi
Illinois.
i
• 434,492 are Seniors and Persons with
Disabilities (SPD) -- used to be called AABD
(Aged Blind Disabled)
• SPDs are 16% of clients but cost 55% of
M di id b
Medicaid
budget
d t ((allll agencies)
i )
• The State is focused on moving this more
expensive population into care coordination
programs; not the TANF population (moms and
kids)
Peterson Healthcare Consulting
Illinois Medicaid Reform signed in 2011
Seniors and Persons with Disabilities (SPD) are of two
t
types:
Medicaid
M di id only
l or D
Duall Eligibles
Eli ibl
Under Age 65 & Disabled
Age 65+:
Total
Medicaid only
y
Duals: Medicaid & Medicare
143,102
19,587
162,689
116,381
153,422
271,803
SPDs will
SPD
ill b
be served
db
by CCE
CCEs, MCCN
MCCNs, MCO
MCOs. H
However,
Medicaid only SPDs will be served only by CCEs &
MCCNs.
Peterson Healthcare Consulting
Illinois Medicaid Reform signed in 2011
For managed care entities:
MCO/MCCN both packages will
MCO/MCCN:
ill be paid thro
through
gh ffullll
risk, capitated rates
package
g services will be p
paid fee-forCCE: service p
service; CCE will be paid through risk-based care
coordination fees. To be awarded October 2012.
LTSS will
ill incorporate
i
t institutional
i tit ti
l care and
d services
i
and supports in Home and Community Based
Services (HCBS ) waivers
Peterson Healthcare Consulting
Illinois Medicaid Reform
Currently, Illinois Medicaid has two managed care
programs:
Voluntary: 222,000 clients have voluntarily enrolled
Includes only children and their parents
Operated by 2 HMOs (Harmony, Meridian & Family Health Network) - in
18 counties
Mandatory: called Integrated Care Program
36,000 Seniors and Persons with Disabilities (SPD) in
Cook County suburbs and 5 collar counties
Operated by 2 MCOs (Aetna Better Health & IlliniCare)
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Illinois Medicaid Reform passed in 2011
State now starting Phase II of the Integrated Care
Program targeting SPD adults
adults.
• For Cook County and 5 collar counties only initially
• Care Coordination Entities (CCEs) and the MCCN
bid this summer and an announcement is
expected in early October.
• 20 proposals
l received
i d tto serve adults
d lt ((and
d
children in their families)
• Targeted for operation beginning January 2013
(likely to be delayed).
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Illinois Medicaid Reform passed in 2011
For Medicaid-only SPD clients, client will:
• Be offered a choice of a managed
g care entity;
y if no
choice is made, then client will be automatically
assigned to an entity
• 60 days to choose a plan and 90 days to change to
another plan
• Enroll into the managed
g care entity
y for both medical
and LTSS service packages (if LTSS is required)
• Be required to use the network of providers offered
b that managed care entit
by
entity and to sta
stay with
ith that
plan for one year (unless the client shows cause for
change to another plan)
Peterson Healthcare Consulting
Illinois Medicaid Reform passed in 2011
To get to 50%, the focus will also include:
(1) Expanding the Medicaid SPD to Central IL and then
areas like Rockford and Quad City
(2) Dual eligible SPD clients - Targeted to phase-in
beginning April 2013 in Greater Chicago and Central
Illinois regions (likely to be delayed) Then on to other
areas in IL
(3) Long-term supports and services package (LTTS )
for SPD clients (including behavioral health, mental
h lth and
health
d substance
b t
abuse
b
services)
i
)
Peterson Healthcare Consulting
Illinois Medicaid Reform passed in 2011
To get to 50%, the focus will also include:
(4) Children with complex health needs - CCEs targeted
for operation beginning April 2013 (again likely to be
delayed).
y )
(5) Mandatory Medicaid SPD enrollment in additional
regions - Targeted to phase-in beginning April 2013
(6) Mandatory managed care for other populations –
children, families, new Medicaid enrollees under
ACA. Targeted
g
to begin
g operations
p
by
y January
y 2014.
Peterson Healthcare Consulting
Illinois Medicaid Reform passed in 2011
Dual-Eligibles (Medicaid/Medicare)
• State has applied to federal Medicare
MedicareMedicaid Alignment Initiative (MMAI)
• Likely to enroll up to an estimated 137,000
SPDs in Cook County, 5 collar counties and
15 counties in central Illinois
• 12 proposals
l received
i db
by 9 companies
i
• No lock in of clients allowed for medical –
Federal Law (State trying to get a waiver on
this for LTSS.)
Peterson Healthcare Consulting
Illinois Medicaid Reform passed in 2011
For Dual Eligible's: Major Insurers bid to serve
this p
population
p
((e.g.,
g BCBS, Humana, Aetna))
• Client will be offered a choice of a managed care
entity; if no choice is made, then client will be
automatically assigned to an entity
• Medicare does not permit mandatory enrollment for
the medical service package
package, so clients can opt-out
opt out of
service package for Medicare medical services
• State is seeking a waiver from federal government to
mandate enrollment into a managed care entity for
Medicaid LTSS service package
Peterson Healthcare Consulting
Illinois Medicaid Reform passed in 2011
For Dual
D al Eligibles:
Eligibles
• Expect announcement regarding who will serve
this population by November 2012.
• Expect program to be implemented in April 2013
if approved by HHS.
HHS
Peterson Healthcare Consulting
Major changes based on 3 new laws
Have Discussed:
1. Illinois Medicaid reform (Public Act
096-1501) – passed in 2011
Now will discuss:
2 More
2.
M
Illi
Illinois
i M
Medicaid
di id reform
f
(Public
Act 097-0689) - passed in May 2012
Peterson Healthcare Consulting
Illinois Medicaid Reform –
SMART ACT passed in 2012
To deal with large State deficit, Illinois
passed more Medicaid reform in May 2012:
The Medicaid budget hole of $2.7 billion was
filled:
•
$1.6 billion from SMART Act reductions (62 specific
spending reductions; some discussed in next slide);
• $700 million revenue from cigarette tax;
• $100 million revenue from the new hospital
assessment; and
• $300 million allocated to Medicaid from increased
state revenues beyond projections(all including 50%
federal match).
match)
Peterson Healthcare Consulting
Illinois Medicaid Reform – 2012 legislation
Some of the SMART Act reductions include:
•
•
•
Eligibility for adults in the Family Care program is
reduced to 133% Federal Poverty Level.
New integrity measures will aggressively target
client and provider fraud.
All provider groups receive a rate cut of 2.7%
2 7%
except for doctors, dentists, FQHCs, safety-net
hospitals and critical access rural hospitals. Other
h
hospitals
it l th
than safety-net
f t
t and
d critical
iti l access
hospitals receive a rate cut of 3.5%.
Peterson Healthcare Consulting
Illinois Medicaid Reform – 2012 legislation
Another key
ke change is that pro
providers
iders m
must
st now
no
submit all claims in 180 days – not 365.
See the following for specifics:
http://www hfs illinois gov/assets/072312n pdf
http://www.hfs.illinois.gov/assets/072312n.pdf
Peterson Healthcare Consulting
Major changes based on 3 new laws
Have Discussed:
1. Illinois Medicaid reform (Public Act
096-1501) – passed in 2011
2 More
2.
M
Illi
Illinois
i M
Medicaid
di id reform
f
(Public
Act 097-0689) - passed in May 2012
Now will discuss Federal Law
3. Affordable Care Act - Signed into law g
on March 23, 2010
Peterson Healthcare Consulting
Overview of Affordable Care Act –
Federal Health Care Reform
• SStates are largely responsible for its implementation
a es a e a ge y espo s b e o s p e e a o
• Phases‐in changes to private health insurance coverage • Significantly expands Medicaid coverage
• Establishes health care exchange to coordinate with Medicaid system
Medicaid system
• State Option to Expand Medicaid to 138% FPL
Authorizes numerous grant programs and pilot
• Authorizes numerous grant programs and pilot projects
Peterson Healthcare Consulting
Key Components of the Affordable Care Act
Affecting Medicaid & the Uninsured
In 2014…and beyond
• Individual Mandate with subsidies for populations
100-400% FPL to purchase health insurance
• State or federal “Health
Health Insurance Exchanges”
Exchanges –
new marketplaces with Essential Health Benefits
package
• Optional Medicaid Expansion to Adults up to 138%
Federal Poverty Level
• No pre
pre-existing
existing condition exclusion; guaranteed
issue; no annual or lifetime limits; and no gender or
health rating.
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Affect of June Supreme Court Decision
• States cannot be financially penalized for failing to
expand Medicaid.
• Illinois plans to implement a state-federal partnership
exchange for at least one year.
• Expects to transition to a state exchange in 2015
2015.
• Governor has announced that Illinois will opt to
p
Medicaid.
expand
• Need legislation to create a State Exchange and to
expand Medicaid in Illinois. Legislature likely to take it
up after
ft the
th November
N
b election.
l ti
• If Obama loses election and Senate moves to
epub ca co
control,
t o , ACA
C poss
possible
b e repeal
epea and
a d replace.
ep ace
Republican
Peterson Healthcare Consulting
Medicaid Expansion: What is it?
• In 2014, anyone under 65, not in Medicare and under
138% of the Federal Poverty Level ($14,521 for an
i di id l/ $29
individual/
$29,965
965 ffor ffamily
il off 4) will
ill be
b eligible
li ibl ffor
Medicaid.
• Federal g
government p
pays
y 100% of the cost of the
extra clients for first 3 years.
• Primary Care MD rates increased to 100% of
M di
Medicare
ffor 2013 and
d 2014 vs. M
Medicaid
di id rates
t –
about a 30% increase.
• Most applications will be filed electronically through
an Integrated Eligibility System with Medicaid and
Health Insurance Exchange. Clients will have a single
point of entry for insurance and Medicaid.
Medicaid
Peterson Healthcare Consulting
Medicaid Expansion: Who is it?
610,821 uninsured individuals in Illinois will be
eligible for new Medicaid “Adult
Adult Group
Group” in 2014
 1,036,706 will become eligible to purchase
i
insurance
th
through
h th
the exchange
h
((with
ith or
without a premium subsidy.)
 In Cook County
County, 330
330,923
923 will be newly eligible
for Medicaid and 394,135 will be eligible to
purchase insurance through the exchange
with a subsidy.
Peterson Healthcare Consulting
Medicaid Expansion: Health Status of Population
•
•
•
•
•
Fair/Poor Health: 18%
Two or More Chronic Conditions: 18%
Limited or Unable to Work: 15%
More Likely to Be Childless Adults Than Parents
Likely to be healthier than nondisabled adults
currently
y enrolled in Medicaid,, but the least
healthy and older individuals are among the new
Medicaid expansion group and are more likely to
enroll.
ll
Source: Robert Wood Johnson Foundation and the Urban Institute, The Health Status of
New Medicaid Enrollees Under Health Reform, August 2010
Peterson Healthcare Consulting
ACA and Non-Citizens
•
•
•
•
Medicaid eligibility remains the same for noncitizens; in general, must be a legal permanent
resident
id t iin country
t for
f 5 years exceptt pregnantt
women and children.
Pregnant
g
women and children remain eligible
g
for
Medicaid regardless of immigration status.
To purchase insurance through exchange with
subsidy
b id only
l need
d tto b
be lawfully
l f ll presentt
(generally Legal Permanent Resident or other
lawful category.)
No coverage for any undocumented non-citizens.
Peterson Healthcare Consulting
Health Care Exchange Legislation
• SB 1555 (now Public Act 097-0142) was signed into law in
August 2011 by the Governor.
Governor
• Created Legislative task force and the Healthcare Reform
Implementation Council to guide Implementation and Design
of the Illinois Health Care Exchange
Exchange.
• Governance and Financial Sustainability are the major
issues.
• Several
S
bills, including HB 4141, were introduced to establish
exchange board and rules but did not pass. The Governor
has recently announced that Illinois will opt to have a statef d l partnership
federal
t
hi exchange
h
ffor fifirstt year.
• Illinois plans to implement a state-based exchange by 2015;
legislation on governance and financing expected in Spring
2013 session.
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Enrollment Issues in 2014
• Enrollment for Single State Entry Point for Medicaid
and Health Insurance Exchange must be available
online, by mail, and in person by 2014.
• There will be roles for Community Based Providers
such as clinics,
clinics social service organizations
organizations, and
hospitals to be navigators and enroll patients.
• The ACA mandates that a Navigator System will be
created using community based providers (most
likely used only for individual enrollment) and the
insurance broker community (most likely used only
for the small business market) in order to educate
and enroll into people the exchange.
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Essential Benefits Package: What is it?
•All health plans sold through
the health care exchange must
cover these essential benefits at
a minimum.
•States can use State
Employee
p y Health Plan,, large
g
insurers, or largest small group
plan as benchmark package.
•Illinois has to decide on their
benchmark plan by 9/30/2012
and accepted comments
through last week.
•Medicaid expansion population
coverage to be determined but
will be benchmarked to EHB..
•Ambulatory patient services;
•Emergency services;
Hospitalization;
•Hospitalization;
•Maternity and newborn care;
•Mental health and substance use
disorder services;;
•Prescription drugs;
•Rehabilitative and habilitative
services and devices;
•Laboratory services;
•Preventive and wellness services
including chronic disease
management;
t
•Pediatric services including oral
and vision care.
Peterson Healthcare Consulting
The Individual Mandate
• Requires most individuals to carry “minimum
essential” health coverage.
• According to Kaiser Family Foundation, Almost 9 in
10 non-elderly people in the US would either satisfy
the mandate automaticallyy or be exempt
p from it.
 Exemptions include: religious reasons,
undocumented immigrants, very low income so do
nott file
fil taxes,
t
insurance
i
premiums
i
exceed
d 8% off
family income
Peterson Healthcare Consulting
Actions Providers Should Take
• Evaluate number of SPD care for: Can tell by the
case number of the individual – starts with a 91, 92,
or 93.
93 F
For D
Duall eligibles,
li ibl
on the
th M
Medicaid
di id card
d on th
the
back under the person’s name will be the following
initials QMB/Medical. This indicates they are dual and
Medicare is primary.
• Must be able to identify SPD when come for care.
Likely will not tell you that they are with a CCE or
HMO. Payment is likely to be denied without prior
authorization for care.
• These individuals will be disproportionately heavy
users of care so important to get their data and model
it
it.
Peterson Healthcare Consulting
Actions Providers Should Take
• Track which organizations win contracts with the
State
• Announced on web site:
http://www2.illinois.gov/hfs/PublicInvolvement/cc/Pages/default.aspx
• Negotiate contracts with the new entities providing
care for SPD – continuity of care is especially
important for these patients
• Many more people will have Medicaid; so demand for
services from MDs who take Medicaid will increase.
Make sure to balance the time allotted to this payor
group to not affect income dramatically.
Peterson Healthcare Consulting
Actions Providers Should Take
• Expected shortage of MDs for the increase in
Medicaid recipients
• PCPs paid Medicare rates; so a positive affect for
treating more Medicaid; but concern re how long this
will last so some hesitant to increase patient base
significantly.
• Shortage of MD specialists who treat Medicaid; so
especially
i ll a challenge.
h ll
• Hospitals lose money on outpatient services to
Medicaid recipients – but will be providing more
services. Must focus on growing areas with higher
margins to offset this.
Peterson Healthcare Consulting
Illinois Information on ACA Implementation
All notices, hearings, proposed regulations and federal
grants are posted on the state health care reform
i l
implementation
t ti website
b it at:
t
http://www2.illinois.gov/gov/healthcarereform/Pages/default.aspx
Mission of IllinoisHealthMatters.org:
To help Illinois individuals, small businesses,
policymakers and community organizations understand
and benefit from improvements and access to health
care under national health care reform.
Peterson Healthcare Consulting
Speakers Info
Stephanie Altman
Health & Disability Advocates
312-265-9070
[email protected]
Cathy A Peterson
P t
Peterson
H
Healthcare
lth
C
Consulting
lti
773-580-6800
cathy peterson@att net
[email protected]
Peterson Healthcare Consulting